punishment for false statement of false attestation that I am

employed by

(Name of Business from which documents are sought) that my official title is (Official Title)

and

I

further state that each of the records attached hereto is the original or a duplicate of the original records in the custody

of

(Name of Business from which documents are sought.) further state that:

I

A) such records were made, at or near the time of the occurrence of the matters set forth, by (or from information transmitted by) a person with knowledge of those matters;

B) such records were kept in the course of a regularly conducted business activity;

C) the business activity made such records as a regular practice; and

D) if such record is not the original, such record is a duplicate of the original.

(Signature)

(Date)

to attest that the documents attached hereto and described below are true copies of the original official records which are

recorded and filed in
(Name of Government Office or Agency)
which is an office or agency of the Government of

(Name of Country)

Description of Documents:

(Signature)

(Title)

(Date)

I relinquished custody of the article(s) to

Person)

(Place)

on

on

(Name of Person)

(Place)

were in the same condition as when I received them (or, if

different, as noted below).

Description of Articles:

Chances in Condition While in my Custody:

(Signature)

(Title)

(Date)